with Maybelle Kou, Inova Fairfax, on the Hot Seat
The Case
This is a case of a 3 year-old girl with noisy breathing and intermittent respiratory distress. For the full case presentation, click here.
Thank you to Dave, Paul, Rasha, Asha, Dewesh, and Jamil for your comments. Click here to read them. Some clinical pearls focused on the importance of synthesizing the exam with clinical picture:
Here's how you answered out questions
1. Would you perform any testing at this time?
One person would do a chest x-ray with inspiratory and expiratory views at this point. If that's not possible, then bilateral decubitus images. Another person would get a chest x-ray AND lateral neck (but this isn't exactly fair since you have to pick one thing).
On re-examination, the patient has more stridor in your ER but is clinically stable.
2. Given the current clinical status, which of the following steps would you take next?
The patient remains the same after your above intervention.
3. What is your next management step?
From the Hot Seat
by Maybelle Kou, Inova Fairfax
Given the patient’s “normal respiratory effort, no position preference and loud upper airway noises”, I am reassured at this minute that this child does not have an acute infectious process with imminent respiratory threat. The illness today is not convincingly croup-like. There is no known “allergen” exposure.
Hoarseness is described, but the history does not support a pharyngeal abscess with this otherwise well appearing child, there is no torticollis, dysphagia or fever. The mouth exam rules out kissing tonsils or tonsillar abscess. The child is immunized, so we don’t need to worry about H flu so much, or diphtheria either. Likewise, her unremarkable body position does not support a fixed mass (such as a huge sublingual mass pressing on the trachea). No rhinorrhea, but was the NP looked at carefully? Must not forget the NP exam after all. I recall my colleague BDC’s story of a child with upper respiratory symptoms similar to the above, who ended up having a long foreign body in his posterior nasopharynx that produced intermittent respiratory symptoms by sliding up and down. Then there was the six month old that was fed plastic stickers by her toddler brother, that adhered to the roof of her mouth and caused intermittent choking when it slid backwards.
Added to the history is a previous “wheezing” event (within 3 months), my thoughts turn to a sub-acute process involving the trachea. The spasmodic nature of the cough could also be suggestive of a foreign body that might be mobile (such as a small piece of plastic). The progressive nature could point towards an enlarging vascular entity, either vascular ring or tracheal hemangioma. One would not expect these to respond verily to bronchodilator treatments. Laryngomalacia should have presented earlier in life. One would also expect to be able to elicit the finding of an extra-laryngeal mass on physical exam in a small child, however, a deep structure might be missed.
Assessment: In short: this is a 3 year old with intermittent respiratory distress with history suggestive of upper airway obstruction, with stable VS and clinical status S/P intervention. Her “wheezing” symptoms are somewhat responsive to inhaled treatments, pointing at inflammation that could be a secondary process.
Management: Give an additional trial of bronchodilators and steroids to address the non-zebras. I would forgive the intern for obtaining an XR. If my eyes do not deceive me, I do not see evidence of tracheal deviation, (so no ring or sling) or obvious foreign body (no ball-valve effect or hyperinflation) and it may just be the projection but the cardiac silhouette may appear a trifle on the large side. The intern and I might later on have a calm discussion about test utilization, and CENTOR criteria, let alone strep tests in general.
MY PLAN: Admit for observation and general surgery consultation for rigid bronchoscopy. She should have a PPD placed, and also have a repeat CXR/swallow study at some point.
Crumbs for thought
1) if you have nasopharyngeal endoscopy and are comfortable using it on a toddler, and the patient can tolerate the test, by all means take a look. Regardless of nasal endoscopy, you can’t see well below the vocal cords, and this child should have a rigid bronchoscopy anyway.
2) In the community setting, most general ENTs/surgeons may will not be comfortable with the age of the child, which would mean the headache of finding one that does, or transferring to a facility for children.
3) There is also the argument that this child has not responded to any treatment, therefore could be stable to be discharged with urgent follow up. Medical/legally, this would require contacting the specialist to arrange the visit for the child. Then there is the issue of where in the airway you think you have a problem. A three year old may not be amenable for an invasive test as an outpatient.
I just had a patient with the “Darth Vader breathing” chief complaint just last week. There must be an ICD-10 code coming.
The Denouement
by Ashley Metcalf, Johns Hopkins
Despite her overall well appearance at the time of initial presentation, a lateral neck films was obtained in addition to the AP chest given her hoarse voice, noisy breathing and recent croup diagnosis with resolution and then recurrence of symptoms. Both chest and neck films were normal and without sign of steeple sign, abnormal tracheal narrowing or obvious foreign body.
Given the child’s change in clinical status, the patient also received bilateral decubitus films to evaluate for evidence of foreign body (ie, air trapping) which were read as normal. A trial of racemic epinephrine was provided with improvement in the stridor but persistent voice change. ENT was contacted but after a brief consultation she was deemed safe for discharge home but arrangements were made to expedite follow up care. She was fit into the schedule the following day where flexible fiberoptic laryngoscopy was performed and she demonstrated a foreign body in the subglottis. The patient was then taken to the OR for SML, bronchoscopy and retrieval of the foreign body.
A hard backed, plastic Mickey Mouse sticker (the kind with googly eyes) was found lodged in the subglottic space with a small amount of granulation tissue. The mother recognized the sticker as one that she had been using at the craft table just prior to her first episode of wheezing three months prior.
The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.
From the Hot Seat
by Maybelle Kou, Inova Fairfax
Given the patient’s “normal respiratory effort, no position preference and loud upper airway noises”, I am reassured at this minute that this child does not have an acute infectious process with imminent respiratory threat. The illness today is not convincingly croup-like. There is no known “allergen” exposure.
Hoarseness is described, but the history does not support a pharyngeal abscess with this otherwise well appearing child, there is no torticollis, dysphagia or fever. The mouth exam rules out kissing tonsils or tonsillar abscess. The child is immunized, so we don’t need to worry about H flu so much, or diphtheria either. Likewise, her unremarkable body position does not support a fixed mass (such as a huge sublingual mass pressing on the trachea). No rhinorrhea, but was the NP looked at carefully? Must not forget the NP exam after all. I recall my colleague BDC’s story of a child with upper respiratory symptoms similar to the above, who ended up having a long foreign body in his posterior nasopharynx that produced intermittent respiratory symptoms by sliding up and down. Then there was the six month old that was fed plastic stickers by her toddler brother, that adhered to the roof of her mouth and caused intermittent choking when it slid backwards.
Added to the history is a previous “wheezing” event (within 3 months), my thoughts turn to a sub-acute process involving the trachea. The spasmodic nature of the cough could also be suggestive of a foreign body that might be mobile (such as a small piece of plastic). The progressive nature could point towards an enlarging vascular entity, either vascular ring or tracheal hemangioma. One would not expect these to respond verily to bronchodilator treatments. Laryngomalacia should have presented earlier in life. One would also expect to be able to elicit the finding of an extra-laryngeal mass on physical exam in a small child, however, a deep structure might be missed.
Assessment: In short: this is a 3 year old with intermittent respiratory distress with history suggestive of upper airway obstruction, with stable VS and clinical status S/P intervention. Her “wheezing” symptoms are somewhat responsive to inhaled treatments, pointing at inflammation that could be a secondary process.
Management: Give an additional trial of bronchodilators and steroids to address the non-zebras. I would forgive the intern for obtaining an XR. If my eyes do not deceive me, I do not see evidence of tracheal deviation, (so no ring or sling) or obvious foreign body (no ball-valve effect or hyperinflation) and it may just be the projection but the cardiac silhouette may appear a trifle on the large side. The intern and I might later on have a calm discussion about test utilization, and CENTOR criteria, let alone strep tests in general.
MY PLAN: Admit for observation and general surgery consultation for rigid bronchoscopy. She should have a PPD placed, and also have a repeat CXR/swallow study at some point.
Crumbs for thought
1) if you have nasopharyngeal endoscopy and are comfortable using it on a toddler, and the patient can tolerate the test, by all means take a look. Regardless of nasal endoscopy, you can’t see well below the vocal cords, and this child should have a rigid bronchoscopy anyway.
2) In the community setting, most general ENTs/surgeons may will not be comfortable with the age of the child, which would mean the headache of finding one that does, or transferring to a facility for children.
3) There is also the argument that this child has not responded to any treatment, therefore could be stable to be discharged with urgent follow up. Medical/legally, this would require contacting the specialist to arrange the visit for the child. Then there is the issue of where in the airway you think you have a problem. A three year old may not be amenable for an invasive test as an outpatient.
I just had a patient with the “Darth Vader breathing” chief complaint just last week. There must be an ICD-10 code coming.
The Denouement
by Ashley Metcalf, Johns Hopkins
Given the child’s change in clinical status, the patient also received bilateral decubitus films to evaluate for evidence of foreign body (ie, air trapping) which were read as normal. A trial of racemic epinephrine was provided with improvement in the stridor but persistent voice change. ENT was contacted but after a brief consultation she was deemed safe for discharge home but arrangements were made to expedite follow up care. She was fit into the schedule the following day where flexible fiberoptic laryngoscopy was performed and she demonstrated a foreign body in the subglottis. The patient was then taken to the OR for SML, bronchoscopy and retrieval of the foreign body.
A hard backed, plastic Mickey Mouse sticker (the kind with googly eyes) was found lodged in the subglottic space with a small amount of granulation tissue. The mother recognized the sticker as one that she had been using at the craft table just prior to her first episode of wheezing three months prior.
The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are written by PEM fellows at Children's National in DC, Johns Hopkins in MD, and INOVA Fairfax in VA. Emily Willner is the faculty advisor on case presentations. We welcome your commentary.
No comments:
Post a Comment
What's your opinion?